The Profile of Diaper Dermatitis in Infants

Cana Rifiza R. S.

, Nelva Karmila Jusuf

, Imam Budi Putra

, Tri Widyawati

Nurfida Khairina Arrasyid

Master Program of Tropical Medicine, Faculty of Medicine, Universitas Sumatera Utara,

Department of Dermatology and Venereology, Faculty of Medicine, Universitas Sumatera Utara

Department of Pharmacology, Faculty of Medicine, Universitas Sumatera Utara

Department of Parasitology, Faculty of Medicine, Universitas Sumatera Utara

Jl. Dr. Mansur No. 5 Medan 20155, Indonesia

*Corresponding author

Keywords: Diaper Dermatitis, Infant

Abstract: Diaper dermatitis is a common condition in infants. The present study aims to describe the profile of diaper

dermatitis in infants. A cross-sectional study was conducted between August and December 2018 in several

hospitals, community health centers and integrated health service in Medan, Indonesia. Age, gender, birth

order, a term or preterm delivery history, feeding history, diaper type used, frequency of diaper changing

and defecation, cleansing agents, diaper cream used, location of rash and skin scraping examination with

10% potassium hydroxide preparation were identified. There were forty infants with diaper dermatitis

included in the study. Of those, 24 infants (60%) were aged 0-6 months, 21 infants (52.5%) were male, and

25 (62.5%) infants were first child. Further, 38 infants (95%) were born a term, 18 infants (45%) were fed

with formula milk, 36 infants (90%) wore disposable diaper, 23 infants (57.5%) had diaper changed <6

times a day, 30 infants (70%) defecated <3 times a day, 17 infants (42.5%) were cleaned with wet wipes,

and 25 infants (62.5%) did not use any diaper cream. Eleven infants (27.5%) had a rash in the inguinal area.

Skin scraping examination with 10% potassium hydroxide preparation showed positive results in 11 patients

(27.5%).

1 INTRODUCTION

Diaper dermatitis is an eruption in the area covered

by the diaper, characterized by erythema, scales, red

plaque, or erosions of skin. It is commonly known as

diaper rash. The covered area includes the lower

abdomen, genital organs, waists, inner thighs,

buttocks and perianal (Stamatas and Tierney, 2014;

Mohamadi et al., 2014).

There are several causes of diaper dermatitis, i.e.

skin friction and irritation, urine and feces, increase

in skin moist and pH, and zinc deficiency (Coughlin

et al., 2014; Blume-peytavi et al., 2014). The three

most common types of diaper dermatitis are chafing

dermatitis, irritant contact dermatitis, and diaper

candidiasis. The prevalence of diaper dermatitis in

general population is 7-35% while among

hospitalized infants and children is 17-43% (Merrill,

2015). The prevalence among countries varied

between 15-84% (Hurdoyal and Pandamikum, 2015;

Li et al., 2012). The incidence of diaper dermatitis is

common in infants aged 3-12 weeks and the peak is

in infants aged 9-12 months. The rate seems to be

similar across male and female (Alonso et al., 2013;

Yaduwanshi and Kumari, 2012).

Infant skin is anatomically and physiologically

different from adults. Although healthy and term

neonates seem to have well-developed skin, the

function of the epidermis is not complete yet (Adam,

2008; Merill, 2015). The epidermis layer of the

infant is characterized by thin stratum corneum and

thin collagen fibers in the dermis layer. A recent

study showed that aterm neonates skin is not

competent and still continues to complete the

maturation process in the first year of life (Agustinus

et al., 2017; Merill, 2015). The epidermis layer as a

skin barrier is not complete yet to prevent water loss

and penetration irritants from the environment.

Further, the infant has a greater tendency to develop

dermatitis. Preterm infant skin has an immature

stratum corneum thus more risky to have an

R. S., C., Jusuf, N., Putra, I., Widyawati, T. and Arrasyid, N.

The Proﬁle of Diaper Dermatitis in Infants.

DOI: 10.5220/0009855800440051

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 44-51

ISBN: 978-989-758-469-5

infection (Agustinus et al., 2017; Atherton et al.,

2016).

Diaper dermatitis can be diagnosed by complete

history taking including the duration, symptoms, risk

factors and appearance of the eruption (Lawton,

2014; Shin, 2014). There are several factors

associated with diaper dermatitis in infants,

including frequency of urination and defecation,

frequency of diaper changes, type of diaper, type of

cleanser, product applied to skin, diet, diarrhea,

recent antibiotic used and any previous diaper

dermatitis (Merill, 2015; Lawton, 2014; Shin, 2014;

Li et al., 2012). Frequent urination and defecation on

covered skin will increase skin pH. Production of

frequent liquid feces means the enzyme is greater

and can act as irritants along with urease enzyme

from the urine. Frequency of urination in neonates is

more than twenty times in 24 hours and will reduce

to around seven times at 12 months of age.

Therefore, frequent diaper changes are important to

do for at least every 3-4 hour (Li et al., 2012).

Improvement of diaper technology associated with

the decrease of the severity of diaper dermatitis. The

absorbent gel makes it possible for a disposable

diaper to keep skin to be dry and maintain the

normal moisture. Cleanser used to cleanse out the

rain and feces is also important because it will

remove the lipid and feces residue from the stratum

corneum (Atherton, 2004; Odio and Thaman, 2014).

The use of barrier cream every diaper change aim to

reduce friction, wetting and contact with urine and

feces. The ideal barrier cream will provide a

longlasting lipid shield which protects the skin from

irritants. (Atherton, 2004; Merill, 2015).

Treatment of diaper dermatitis varies depending

on the severity and etiology. Current practice

including the most recent guideline on neonatal skin

care from the Association of Women's Health,

Obstetric and Neonatal Nurses (AWHONN, 2013)

recommends five approaches for prevention and

treatment of diaper dermatitis. The approaches are

nonpharmacologic solutions easily summarizes into

the "ABCDE" that include air, barrier, cleansing,

diapering, and education. The first is to expose the

diaper area frequently to air as much as possible.

Apply barrier cream to skin for infants at risk of

diaper dermatitis or whenever diaper dermatitis is

present. The skin should be cleansed gently with

water and soft cloth or wipes at every diaper change.

Use of superabsorbent diaper is recommended and

the diaper should be changed as soon as the diaper is

soiled at least every 3 hours during the day and once

during the night. Parents must be educated for diaper

hygiene and good skin practices (Merill, 2015;

Pogacar et al., 2018; Serdaroglu and Ustunbas,

2010).

Diaper dermatitis can improve in a couple of

days with good skin practices. A skin infection may

develop if diaper dermatitis is not managed well.

One of the most common infection occurred is

caused by fungal. Candida is fungal that often

infects skin with diaper dermatitis. When it is

suspected, the skin scraping examination with 10%

potassium hydroxide can be done to identify the

fungal structure such as hyphae, pseudohyphae or

spore (Bonifaz et al., 2016). If it is confirmed,

topical antifungal can be given as the choice for

treatment for diaper dermatitis.

Several studies in Indonesia has been conducted

to evaluate parents knowledge about diaper

dermatitis (Ullya et al., 2018; Kusumastuti and

Alfiyanti, 2017; Jahidin, 2015) however studies on

the profile of diaper dermatitis in infants and skin

scraping examination with 10% potassium

hydroxide to find fungal infection are still limited.

The aim of this study is to describe the profile of

diaper dermatitis in infants at health service centers

in Medan, Indonesia. The health service centers

included in this study are the hospital, community

health center (known as Puskesmas) and integrated

health service center (known as Posyandu).

2 METHODS

This cross-sectional study was conducted between

August and December 2018 at one General Hospital,

one Hospital Women and Children, two community

health centers and integrated health service centers

(Posyandu in the two Puskesmas area) in Medan,

Indonesia. Subjects were infants who were inpatient

at the two hospitals, and infants who were attending

the two Puskesmas and Posyandu. Inclusion criteria

included infants aged 0-24 months, wore a diaper

and had diaper dermatitis at the time of the study.

Exclusion criteria included infants who used the

antifungal topical cream on skin covered by the

diaper and had oral antibiotics at the time of the

study. Forty patients who were fulfilled the selection

criteria participated in the study.

Parents or guardians were given written informed

consent before enrolment of the children to the

study. The required information was being asked to

the parents or guardians and then the diaper rash was

observed carefully. Skin scrapping was collected

with a sterile pot and analyzed at the clinical

microbiology laboratory in the General Hospital.

Samples were labeled with name, age, and gender.

The Proﬁle of Diaper Dermatitis in Infants

Skin scraping sample was prepared with 10%

potassium hydroxide preparation and examined

under a microscope. Microscopic findings were used

to identify the presence of fungi, i.e. hyphae, and

spore they were confirmed as a positive result.

Data processing using Statistical Package for the

Social Science (SPSS) version 22.0 was presented

descriptively to see the percentage of profile diaper

dermatitis in infants in the present study.

The protocol of this study has been approved by

the Ethics Committee of Faculty of Medicine,

Universitas Sumatera Utara with ethical clearance

No: 446/TGL/KEPK FK USU-RSUP HAM/2018.

3 RESULTS

A total of 40 patients were included in this study. Of

those, 13 patients were enrolled at the General

Hospital (8 male, 5 female), 6 patients were at

Women and Children’s Hospital (3 male, 3 female),

2 patients were at the Puskesmas (2 male), and 19

were at the Posyandu (8 male, 11 female).

Demographic characteristics are described in

Table 1. Infants aged 0-6 months was the most

prevalent of all age groups (n=24, 60%), and the

male was found to be more common (n=21, 52.5%).

Of those, most were first child (n=25, 62.5%).

Table 2 showed the profile of diaper dermatitis in

infants as follows: born at full-term (n=38, 95.0%),

infants fed with formula milk (n=18, 45.0%), worn

disposable diaper (n=36, 90%), frequency of diaper

change <6 times a day (n=23, 57.5%), frequency of

defecation <3 times a day (n=30, 75.0%), cleansed

using wet wipes (n=17, 42.5%) and did not use a

diaper cream (n=25, 62,5%).

On rash examination, we found that the most

common location of the rash was inguinal area

(n=11, 27.5%), as shown in Table 3.

Skin scraping examination with 10% potassium

hydroxide showed positive result only in 27.5% of

infants (n=11). The assay also found hyphae in 2

samples, pseudohyphae in 9 samples. And there was

no spore identified (Table 4).

Table 1: Demographic Characteristic of Infants

Characteristics

Place of Study

Total %

General

Hospital

Women

and Children Hospital

Puskesmas Posyandu

Gender

Male 8 3 2 8 21 52.5

Female 5 3 0 11 19 47.5

Age (month)

0-6 7 6 1 10 24 60.0

7-13 6 0 1 7 14 35.0

14-20 0 0 0 1 1 2.5

21-24 0 0 0 1 1 2.5

Birth Order

6 5 0 14 25 62.5

6 1 0 2 9 22.5

≥ 3

1 0 2 3 6 15.0

Table 2: Profile of Diaper Dermatitis in Infants

Profile

Place of Study Total (%)

General

Hospital

Women

and Children

Hospital

Puskesmas

Posyandu

Delivery history

A term 11 6 2 19 38 95.0

Preterm 2 0 0 0 2 5.0

Feeding history

Breastfeeding 3 2 1 11 17 42.5

Formula milk 7 3 1 7 18 45.0

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

Breastfeeding and

formula milk

3 1 0 1 5 12.5

Type of Diaper

Cloth diaper 0 0 0 3 3 8.3

Disposable diaper 13 6 1 16 36 90.0

Modern cloth diaper 0 0 1 0 1 1,7

Frequency of diaper

changing

<6 times/day 5 3 1 14 23 57.5

≥6 times/day 8 3 1 5 17 2.5

Frequency of defecation

<3 times/day 8 4 0 18 30 75.0

≥3 times/day 5 2 2 1 10 25.0

Cleansing agents

Water only 4 2 0 7 13 32.5

Water and soap 2 1 1 6 10

Wet wipes 7 3 1 6 17 42.5

Diaper cream

Never 7 6 0 12 25 62.5

Always 1 0 0 1 2 5.0

Sometimes 5 0 2 6 13 32.5

Table 3: Location of Diaper Dermatitis Rash

Location

of Rash

Place of Study

Total %

General

Hospital

Women and

Children Hospital

Puskesmas Posyandu

Genitalia 0 0 0 4 4 10.0

Pubic 1 0 0 2 3 7.5

Inguinal (R/L) 5 1 1 4 11 27.5

Femoral (R/L) 0 0 0 1 1 2.5

Perineum 1 0 0 0 1 2.5

Perianal 3 2 1 4 10 25.0

Gluteal 2 3 0 2 7 17.5

Genitalia and public 1 0 0 2 3 7.5

Inguinal and femoral 0 0 0 0 0 0

R=right, L=left

Table 4: Skin Scrapping Examination with 10% potassium hydroxide

Result

Microscopic Finding

Total %

Spore Hyphae Pseudohyphae

Positive 0 2 9 11 27.5

Negative 0 0 29 29 72.5

4 DISCUSSION

This study described the diaper dermatitis profile in

infants attending the General Hospital, Women and

Children’s Hospital, Puskesmas and Posyandu in

Medan, Indonesia. In the present study, subjects

with diaper dermatitis were aged between 0-24

months. Infants aged between 0 and 6 months was

the most prevalent among other age groups. The

prevalence of diaper dermatitis was likely to

decrease correspondingly with the increase of

infant's age. This condition is associated with the

incompetent stratum corneum of the neonates. A

recent study has shown that full maturation of

stratum corneum might not be complete until one

The Proﬁle of Diaper Dermatitis in Infants

year of age (Nikolovski et al., 2008). It has also been

associated with the skin pH of the neonates. At birth,

the pH has been reported to be around 7.80, which is

higher than 5.7 measured in adults. However, the

level of Ph declines after several weeks of life

(Yosipovitch et al., 2000; Horowitz et al., 2013;

Fluhr et al., 2012). The development of stratum

corneum and the decline of skin pH to be more

acidic are important as the barrier function and as an

antimicrobial defense of the skin. Therefore,

younger infants are more prone to be at risk for

dermatitis. Nevertheless, some other studies have

described that diaper dermatitis was frequently

found among infants aged 6 to 12 months which

might be associated with feeding (Hurdoyal and

Pandamikum, 2015; Yaduwanshi and Kumari,

2012). Li et al., (2012) reported the incidence of

diaper dermatitis tends to increase along with the

increase of age and the peak was infants aged 19-24

months. Adalat et al., (2007) found infants aged 12-

24 months aged to be the most prevalent followed by

aged 6-12 months. Infants aged higher than six

months has given solid foods diet, causing the

adaptation process of the digestive tract and also the

change of digestive enzyme (Hurdoyal and

Pandamikum, 2015; Yaduwanshi and Kumari,

2012).

Diaper dermatitis is a common condition found

in infants and children. The prevalence and

incidence varied among countries around the world.

It is associated with many risk factors such as type

of diaper, duration of diaper use, skin hygiene

practice, and different childcare practices (Andrini,

2016; Merrill, 2012).

In this study, male infants were more common.

Several previous studies reported the same results

(Hurdoyal and Pandamikum, 2015; Frilasari, 2016;

Mohamadi et al., 2014). Other studies stated that

gender is not significantly different compared to the

control subjects (Li et al., 2012; Elfaituri et al.,

2016). But in contrast to those studies,

Yaduwanshi and Kumari (2012) and Blanco and van

Rossem (2013) reported female subjects are greater

in infant's diaper dermatitis.

In the present study, we found that most infants

are the first child in the family. This might be due to

the lack of experience and knowledge of baby care.

New parents often follow the method of babysitting

by the grandparents, but some of them do not look

for information online or ask experienced friends.

This often happens because most working parents

entrust the baby to the grandparents when they are at

work. However, this theory still needs to be studied

to prove the relationship.

We also found that infants born at a term

gestational pregnancy age to be more common. This

is in accordance with a previous study stating that

healthy, a term neonate's skin does not completely

mature to function as a barrier toward irritants and

infections (Adam, 2008; Merill, 2015; Agustinus et

al., 2017). Infants who were fed with formula milk

also had more diaper dermatitis in this study. It has

been reported that breastfed children have a lower

prevalence of diaper dermatitis because their feces

have a higher pH, lower digestive enzyme activity

and less urease-producing bacteria than formula

milk-fed children (Yoshioka et al., 1983).

Further, infants with a disposable diaper with

diaper changes <6 times a day had more diaper

dermatitis in this study. Li et al., (2012) reported the

same findings. This is due to the skin covered by

diaper get more moisture and humidity which can

lead to maceration. Thus, frequent diaper changes

are good to maintain skin dryness.

In the present study, most infants did not have

diarrhea at the time of the study. Diarrhea may be an

important risk factor to develop diaper dermatitis.

Frequent exposure to liquid feces is associated with

greater amounts of an enzyme which pass with the

feces (Atherton, 2001).

Wet wipes have been used widely as an

alternative to cleansing the skin. In this study,

parents or guardians had already worn wet wipes as

an alternative to water and soap. The use of wet

wipes consider to be better in reducing the

occurrence of diaper dermatitis is infants

(Ehretsmann et al., 2001). Diaper creams may also

provide a protective lipid film that prevents exposure

to irritants (Stamatas and Tierney, 2014). Diaper

cream should be applied at every diaper change for

infants at risk of developing diaper dermatitis and

whenever diaper dermatitis is present (Atherton,

2016; Noonan et al., 2006). In this study, parents did

not yet use any diaper cream because of the lack of

information on the function of diaper cream as a

protector for infant skin.

The location of diaper dermatitis rash was found

greater in the inguinal area, followed by the perianal

area. Andrini (2016) also reported that inguinal to be

the most affected area in diaper dermatitis subjects.

The rash in covered diaper skin often appears in the

area which contacts with diaper and gets more

friction. The skin folds and convex area of gluteal

are also frequently affected because of the high

humidity (Adam, 2008; Alonso et al., 2013).

Most infants with diaper dermatitis were found at

the Posyandu in this present study. Posyandu is a

place which health activities organized from, by and

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

for communities assisted by health workers from

Puskesmas. It primarily starts to serve not only

babies and toddlers but also the elderly. Baby health

services specifically in weighing and immunization

is common, but baby caring is not done routinely.

Skin scraping examination is easy, cheap and can

be done immediately. The examination is important

to identify fungal infection, thus clinicians can

choose the appropriate treatment for diaper

dermatitis. The sensitivity of this test is about 60%,

thus the possibility to detect fungal infection is still

high (Mutiawati, 2016; Sari et al., 2013). The

percentage of skin scrapping examination with 10%

potassium hydroxide preparation in this study is

different from the previous study. Blanco and van

Rossem (2013) has shown that the positivity of

diaper dermatitis in infants was 59%. The role of

fungal infection in diaper dermatitis has been studied

in other studies. The most common fungal infection

associated with diaper dermatitis is Candida,

especially Candida albicans, which has been

reported in more than 80% of cases (Klunk et al.,

2014; Ferrazini et al., 2003). Normally the number

of Candida in the diaper area without dermatitis is

low and yeasts are isolated in <4% of cases, while

they are present between 70 and 92% of children

with diaper dermatitis (Adalat et al., 2007; Adam,

2008).

There are a few limitations in this study. First,

the numbers of samples enrolled in this study was

relatively small. Second, there is no control subjects

participated in this study. However, this study

showed that diaper dermatitis is a common problem

during infancy and fungal infection is still common

to present as a secondary infection. The further

comprehensive study is needed to be done.

5 CONCLUSION

1. The proportion of diaper dermatitis in this study

was greater among infants aged 0-6 months, the

male was found to be the most common

compared to female, and the first child was also

commonly found.

2. The present study showed that most infants with

diaper dermatitis were born a term, fed with

formula milk, wore a disposable diaper, had a

diaper changed <6 times a day, defecated <3

times a day, cleansed with wet wipes and did

not use any diaper cream.

3. The location of rash in the diaper dermatitis

varied in this study. Inguinal was the most

affected area, followed by the perianal area.

4. The percentage of fungal infection in the diaper

dermatitis in this study was 27.5% as confirmed

by a skin scraping examination with 10%

potassium hydroxide preparation.

6 SUGGESTION

1. Special care for infants with diaper dermatitis in

the hospital needs to be done carefully by

doctors and nurses in the pediatric room.

2. Joint care of pediatrician and dermatologist for

the prevention and treatment of infants with

diaper dermatitis in hospital needs to be done

continuously (integrated care).

3. Health workers in Puskesmas and Posyandu

need to be trained about the good skin care

practice for infants so that they can educate the

parents.

4. Fungal culture examination as the gold standard

can be done in further study to explain the role

of fungal as the cause of diaper dermatitis.

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